MGMA ACA Exchange Implementation Survey Report. May 2014

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1 MGMA ACA Exchange Implementation Survey Report May 2014

2 Overview Medical Group Management Association (MGMA) conducted member research in April 2014 to better understand the impact of the Affordable Care Act s (ACA) insurance exchange implementation on medical group practices. This research follows up our September 2013 study, which helped shed light on a number of ACA exchange implementation issues. The survey includes responses from more than 700 medical groups in which more than 40,000 physicians practice nationwide. Almost 80% of survey respondents reported their practice is participating with new health insurance products sold on the ACA exchanges (ACA exchange products) and more than 90% of these practices have already seen patients with this coverage. Of practices participating with ACA exchange products, 85% are contracting with one to five products and almost 60% reported they are participating in order to remain competitive in their local market. While more than 8 million consumers have enrolled in health insurance coverage through the ACA exchanges, 56% of respondents reported no change in their practice s patient population size through April and 24% reported a slight increase. Practices expect a small shift in this trend through the end of the year. Thirty percent of respondents projected no change to their practice population size by the end of 2014 and 44% predicted a slight increase. These figures illustrate that most practices are not being inundated by new ACA exchange patients but do expect to treat somewhat more of these patients as the year progresses. This research also revealed key issues practices are experiencing with ACA exchange implementation. 2

3 Summary of Findings MGMA noted three main themes within the findings. Obtaining coverage information Practices have experienced difficulty identifying patients with ACA exchange coverage and obtaining essential information related to that coverage. 62% of respondents reported moderate to extreme difficulty with identifying a patient that has ACA exchange coverage as opposed to traditional commercial health insurance. Compared to patients with traditional commercial coverage, nearly 60% of respondents indicated that for patients with ACA exchange coverage it is somewhat or much more difficult to: Verify patient eligibility Obtain cost-sharing or network information Obtain information about the plan s provider network in order to facilitate referrals We are going to have to hire additional staff just to manage the insurance verification processs. Identification of ACA plans has been an administrative nightmare. We thought we would be able to identify ACA insurance exchange products by their insurance card, but quickly found out this isn t so. Patient cost-sharing Practices are facing a number of challenges related to patient cost-sharing for ACA exchange coverage. 75% of respondents reported that patients with ACA exchange coverage are very or extremely likely to have high deductibles compared to patients with traditional commercial coverage. Practices reported significant patient confusion about the substantial cost-sharing related to many ACA exchange products, and practices are working to help patients understand the complexities of their coverage. Practices cited some of the main reasons for not participating with ACA exchange products were related to concerns about financial burdens from patient collections (such as burdens related to collecting high deductibles from patients and concerns about financial liability from the 90-day grace period). Patients have been very confused about benefits and their portion of the cost. Once the patients find out their deductible, they ve cancelled appointments and procedures. The at-risk piece of eligibility is tremendously hard to determine and explain to patients. Patients don t always understand how health insurance works, so we ve been engaging in educational events for the community. 3

4 Network limitations Practices have concerns about the impact of the network design of many ACA exchange products. Almost half of respondents reported they have been unable to provide covered services to ACA exchange patients because the practice is out of network. 20% of respondents reported that their practice was excluded from a narrow network that they would have liked to participate in and 10% of respondents chose not to participate in a narrow network. Narrow networks may create challenges related to patient referrals for appropriate treatment and hospital care. Even if the practice is included in the network, without robust representation by a wide range of providers, it may be difficult for a practice to coordinate a continuum of care consistent with the patient s needs. Many patients purchased products with a very narrow network and didn't understand the ramifications. They are very upset once they learn that they can't go to the specialist or hospital of their choice. As primary care providers, we are now faced with the extra burden of trying to find them care within their new narrow network. Payer directories are woefully inaccurate and impossible to rely on. Former patients were shocked to learn about their very narrow network of providers. It was terrible to have to inform them of their lack of coverage. We are consistently denied "out of network" approvals for the very sick who truly need to continue their care with providers who have worked with the patient for years. 4

5 1. Overall, how favorable or unfavorable do you think the impact of the ACA insurance exchanges will be on your practice? Very unfavorable Unfavorable Neutral Favorable Very favorable 15.1% 44.3% 26.8% 11.3% 2.5% 2. Is your practice participating with any new health insurance product(s) sold on an ACA exchange (ACA insurance exchange products)? Response Yes 76.5% No 23.5% 5

6 3. Practices not participating with any ACA insurance exchange products cited the following as reasons why (check all that apply): Response Concerns about assuming financial liability during a 90-day grace period for ACA exchange enrollees 48.1% Our practice was not approached by payers in our area with contracts for any ACA exchange products 41.8% Concerns about financial burdens from patient collections (ex. from high deductibles) 41.1% Based on low reimbursement rates, participating would pose a financial risk for our practice 38% Concerns about the administrative and regulatory burdens related to these products 31.6% 6

7 4. Practices that are participating with ACA insurance exchange products cited the following as reasons why (check all that apply): Response To remain competitive in our local market 57.6% Opportunity to replace current charity care as our uninsured patients obtain coverage 39% Opportunity to provide care to an underserved patient population 35.4% Inability to select patients based on their insurance (ex. as a result of hospital affiliation) 22.8% Favorable reimbursement rates offer a good financial opportunity for our practice 14% 7

8 Questions 5 12 only include responses from practices that are participating with ACA exchange products. 5. How many ACA insurance exchange products is your practice participating with? Response % % % % More than % 8

9 6. On average, how do payment rates offered by ACA exchange insurers compare to: Much lower Somewhat lower Equal Somewhat higher Much higher Do not know Average payment rates from all of your traditional commercial contracts Other traditional commercial products offered by the same payer(s) 18.2% 32% 36.6% 2.1% 0.6% 10.5% 15.4% 30.2% 41.8% 2.1% 0.8% 9.7% Traditional Medicare (i.e., not Medicare Advantage) 8.3% 17.1% 32.7% 23.5% 6.6% 11.8% Medicaid 5.6% 6.9% 28.5% 28.8% 17.6% 12.7% 7. To date, has your practice seen patients with ACA insurance exchange coverage? Response Yes 93.9% No 6.1% 9

10 8. What impact have ACA insurance exchange products had so far on your practice s patient population size? Decreased significantly Decreased slightly No change Increased slightly Increased significantly Do not know 1.2% 9.6% 56.4% 24.4% 1.4% 7% 9. What impact do you expect ACA insurance exchange products will have on your practice s patient population size by the end of 2014? Decrease significantly Decrease slightly No change Increase slightly Increase significantly Do not know 2.1% 10.2% 29.2% 44.3% 7.5% 6.7% 10

11 10. How difficult has your practice found it to distinguish between a patient that has ACA insurance exchange coverage as opposed to traditional commercial health insurance (not related to the ACA exchanges)? Not at all difficult Slightly difficult Moderately difficult Very difficult Extremely difficult 12.4% 25.5% 30.6% 21.4% 10.1% 11. Of the patients your practice has seen with ACA insurance exchange coverage, how difficult have you found the following tasks compared to patients with traditional commercial coverage? Much easier Somewhat easier No difference Somewhat more difficult Much more difficult Do not know Verifying patient eligibility 0% 0.5% 34.1% 25.5% 37.7% 2.3% Obtaining cost-sharing information 0% 0.7% 31% 25% 37.3% 6% Obtaining information about the plan s provider network in order to facilitate referrals Obtaining information related to the plan s prescription drug formulary 0.2% 0.7% 33.6% 22.1% 36.5% 7% 0.3% 1% 38.7% 19.1% 24% 17% 11

12 12. Based on the patients your practice has seen with ACA insurance exchange coverage, on average, how likely are these patients to have high deductibles compared to patients with traditional commercial coverage? Not likely Somewhat likely Very likely Extremely likely Not applicable 2.9% 19.7% 32.1% 43% 2.2% Question 13 and 14 include all survey respondents. 13. To date, has your practice seen patients with ACA insurance exchange coverage that you were unable to provide covered services to because your practice was not included in that ACA insurance exchange product s network? Response No 47.4% Yes 40.9% Do not know 11.7% 12

13 14. Many ACA insurance exchange products are using narrow networks/limited provider panels. Has your practice been excluded from a network that you would like to be included in? Response No 50.5% Yes 19.9% Do not know 16.1% Our practice chose not to participate in a narrow network 10% Not applicable 3.5% 13

14 Respondent Demographics Participation Total State 728 practices in which over 40,000 physicians practice All but four states participated: North Dakota, Rhode Island, West Virginia and Hawaii Practice Size Mean Median 55.7 FTE physicians 10 FTE physicians Organization Type Independent medical practice 75.1% Hospital or integrated delivery system (IDS), or medical practice owned by hospital of IDS Medical school faculty practice plan or academic clinical science department Federally qualified health center, community health center or similar practice 11.7% 4.2% 2.3% Freestanding ambulatory surgery center (ASC) 1.5% 14

15 Respondent Demographics Specialty Total: 42 specialties participated Highest participation by specialty 1. Multispecialty with primary and specialty care 19.3% 2. Orthopedic surgery 10% 3. Family practice 8.3% 4. Ob/gyn 6.6% 5. Gastroenterology 5.3% 6. Pediatrics 4.7% 7. Urology 3.7% 8. Internal medicine 3.2% 9. Multispecialty with specialty care only 2.4% 10. Cardiology 2.8% Visit mgma.org and the MGMA ACA Resource Center for additional information on healthcare reform and ACA implementation resources. 15

16 About MGMA The Medical Group Management Association (MGMA) helps create successful medical practices that deliver the highest-quality patient care. As the leading association for medical practice administrators and executives since 1926, MGMA helps improve members practices through exclusive member benefits, education, resources, news, information, advocacy, and networking opportunities, and produces some of the most credible and robust medical practice economic data and data solutions in the industry. Through its industry-leading ACMPE board certification and Fellowship programs, MGMA advances the profession of medical practice management. Through its national membership and 50 state affiliates, MGMA represents more than 33,000 medical practice administrators and executives in practices of all sizes, types, structures and specialties. MGMA is headquartered in Englewood, Colo., with a Government Affairs office in Washington, D.C. Contact MGMA Government Affairs: Contact MGMA Media Relations: , ext. 1332

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